Download Clinical Uses of Metronidazole in Paediatric Dentistry

Int J Pharma Res Health Sci. 2016; 4 (4): 1276-1279
DOI:10.21276/ijprhs.2016.04.05
CODEN (USA)-IJPRUR, e-ISSN: 2348-6465
SK Mallineni et al.
International Journal of Pharma Research and Health Sciences
Available online at www.pharmahealthsciences.net
Review Article
Clinical Uses of Metronidazole in Paediatric Dentistry
Anupam Saha 1, Sreekanth Kumar Mallineni 2, *, Rekha lakshmi Kamatham 3, Sivakumar
Nuvvula 4
1
Postgraduate student, Department of Paedodontics and Preventive Dentistry, Narayana Dental College & Hospital, Nellore,
Andhra Pradesh, India.
2, 3
Reader, Department of Paedodontics and Preventive Dentistry, Narayana Dental College & Hospital, Nellore, Andhra
Pradesh, India.
4
Professor, Department of Paedodontics and Preventive Dentistry, Narayana Dental College & Hospital, Nellore, Andhra
Pradesh, India.
ABSTRACT
ARTICLE INFO
Received: 01 Aug 2016
Accepted: 28 Aug 2016
Metronidazole has been widely used in clinical dentistry, is specifically anti-anaerobic in
nature and known for its effective antibacterial activity against anaerobic cocci as well as
Gram-negative and Gram-positive bacilli. It has been used both systemically and topically in
the treatment of periodontal disease. Application of its uses in paediatric dentistry is limited.
The importance of metronidazole in paediatric dentistry has not been clearly demonstrated.
Hence, the purpose of this short communication was to review uses of metronidazole in
children with dental problems.
________
KEY WORDS: metronidazole, antimicrobial, paediatric dentistry, children
1. INTRODUCTION
Corresponding author *
Dr. Sreekanth Kumar Mallineni
Reader, Department of Paedodontics and Preventive
Dentistry
Narayana Dental College & Hospital
Nellore, Andhra Pradesh, India.
Email ID: [email protected]
Antibacterial activity against clinically important anaerobes
has been found with nitroimidazole derivatives.
Metronidazole,l-(2-hydroxycthyl)-2-methyl-5nitroimidazole,
which is a nitroheterocyclic compound ,is specifically antianaerobic in nature and has a broad spectrum of activity
against protozoa and anaerobic bacteria.1 Metronidazole was
introduced as an anti-trichomonal agent via classical
pharmaco-chemical steps, but has progressed as a useful
IIIIIIIII© International Journal of Pharma Research and Health Sciences. All rights reserved
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Int J Pharma Res Health Sci. 2016; 4 (4): 1276-1279
drug in a variety of disparate fields. It was first used in
clinical trial in 1958, after its synthesis from a crude extract
of streptomycete.2 Durel and co-workers3 further reported its
use in the treatment of infections caused by Trichomonas
vaginalis. Subsequently, it was used in the infections caused
by Entamoeba histolytic and Giardia lamblia. Inference of
metronidazole on oral diseases was initially done by Shinn4
as he observed successful resolution of acute ulcerative
gingivitis in patients receiving concurrent metronidazole for
trichomoniasis.2 Nonetheless, metronidazole had been
progressed from near ideal anti-trichomonal agent to far
more useful drug in a variety of heterogeneous fields. The
advantages of metronidazole have been shown in Table 1.
Metronidazole is available as oral, intravenous, vaginal, and
topical formulations. It is well absorbed after oral
administration, and reaches peak plasma concentrations
within 1–2 hours after consumption. The drug itself is a
major component in plasma with the limited amount of
active metabolites.6 Main therapeutic advantage of
metronidazole is removal of pathogenic anaerobes, without
disturbing protective aerobic flora. The drug does not
develop resistance among anaerobes as suggested by the
consensus of clinical and experimental evidence, which is
due to decreased uptake of drug, reduced drug efficiency or
prevention of entry of the drug or efflux.2,6 There is no
problem of re-administration of metronidazole. Hence, its
use in dentistry does not exclude its immediate reuse
systemically, which has made the drug as ‘priority drug’. 2
Advantages of using triple antibiotic paste prior to
endodontic regenerative procedure may conserve any viable
tissue and allows the root thickness and length, resembling
normal maturation of the root.10 Bose and co-workers11
compared triple antibiotic paste, calcium hydroxide and
formocresol as intra-canal medicament in non-vital young
permanent teeth, and reported highest percentage of increase
in dentin wall thickness in triple antibiotic paste group. The
paste mainly contains bactericidal (metronidazole,
ciprofloxacin) and a bacteriostatic (minocycline) agent that
aid in successful revascularisation and also helps to promote
functional development of pulp dentin complex.12
2.3 INTRACANAL MEDICAMENT:
Metronidazole can be used as an effective intra-canal
medicament. Siqueira and de Uzeda13 evaluated the
antibacterial activity of 0.12% chlorhexidine gel, 10%
metronidazole gel, calcium hydroxide plus distilled water,
calcium hydroxide plus camphorated paramonochlorophenol
(CPMC) and calcium hydroxide plus glycerine using an agar
diffusion test. Authors found that, metronidazole caused
inhibition of growth of all obligate anaerobes tested and
showed better effectiveness than calcium hydroxide/ CMPC
paste against two of the strains, whereas, calcium hydroxide/
CMPC paste and chlorhexidine were effective against all
bacterial strains tested.
Kargul and co-workers5 conducted a clinical trial, where
metronidazole has been used as intra-canal medicament
combined with pulpectomy in infected primary molars.
When freshly mixed metronidazole cream was applied as
intra-canal medicament for one week, it has shown success
2.
APPLICATION
IN
PAEDIATRIC
rate of 85% after 24 months, which proves metronidazole’s
DENTISTRY
effectiveness against endodontic bacteria which are mainly
2.1 AS ORAL MEDICAMENT:
Metronidazole is the most commonly prescribed antibiotic
obligate anaerobes. Hoshino and co-workers9 evaluated the
for pulpal infections in both primary and permanent teeth
antibacterial
efficacy of
mixture
(Metronidazole,
after amoxicillin. Two main reasons for its use in Paediatric
Ciprofloxacin and Minocycline, with and without
dentistry are control of oral infection and prevention of
Rifampicin) on the bacteria from infected dentin of root
subacute bacterial endocarditis. It is primarily prescribed as
canal walls, and authors reported that this drug combination
an adjunct to the treatment in abscess condition where
is sufficiently potent in eradicating bacteria from infected
periapical tissue becomes involved. Main purpose of its
dentin of root canals. Although, metronidazole can be used
prescription in this condition is to limit swelling, as well as
as intra-canal medicament causing inhibition of growth of all
metastasis of infection to vital organs.7 Tanwir and coobligate anaerobes and more effective than other intra-canal
workers8 conducted a cross sectional study to evaluate the
medicaments in eliminating obligate anaerobes with in root
pattern of antibiotic and painkiller prescription as per
canal.
diagnosis by dentists and concluded that amoxicillin and
2.4 OBTURATING MATERIAL:
metronidazole were the most commonly prescribed
Metronidazole has been used as an obturating material along
antibiotics for dental problems such as caries/pulpitis. This
with two other antibiotic drugs in lesion sterilization and
drug has been prescribed under the trade name of Flagyl at a
tissue repair (LSTR) therapy or non-instrumentation
dosage of 200 mg (BID).
endodontic treatment (NIET).This is a new biologic
approach in the treatment of carious lesions with or without
2.2 ENDODONTIC REGENERATIVE PROCEDURE:
Regenerative procedure is an alternate clinical approach for
pulpal and periapical involvement. When the conventional
apexification and involves the use of triple antibiotic paste
endodontic therapy is not possible or if the teeth show
(metronidazole, ciprofloxacin, and minocycline) as a
presence of external or internal resorption, this technique is
dressing to sterilise the root canal before the induction of
used as adjuvant. This concept employs a mixture of three
bleeding to create a matrix for the in growth of new vital
antibiotic drugs viz. ciprofloxacin, metronidazole and
tissue in the pulp canal space.9
minocycline in a ratio of 1:3:3, which can sterilize carious
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IIIIIIIII© International Journal of Pharma Research and Health Sciences. All rights reserved
Int J Pharma Res Health Sci. 2016; 4 (4): 1276-1279
lesions, necrotic pulps, and infected root dentine of primary
teeth. LSTR technique prevents unnecessary irritation of the
periapical tissues, as there will be no mechanical
instrumentation of the root canals. Metronidazole cannot
eradicate all bacteria from the carious lesions even in
maximum concentration. Hence, there is necessity of
additional drugs to make the lesion sterile.14 The triple
antibiotic (3 Mix) powder is mixed along with macrogel and
propylene glycol, acts as a vehicle and enhance the
penetration ability of the drug into infected root canal
dentin.15Triple antibiotic paste is biocompatible with
tetracycline
inhibiting
collagenases
and
matrix
metalloproteinases,
whereas
metronidazole
and
ciprofloxacin in triple antibiotic paste generate fibroblasts.10
Kayalvizhi and co-workers16 conducted a literature review
on LSTR therapy in primary teeth and concluded, successful
resolution with 3 Mix paste in LSTR therapy. The antibiotic
drugs used in LSTR offer a few disadvantages when used
alone, as ciprofloxacin has reduced activity against
anaerobes, while metronidazole was ineffective against
facultative bacteria and minocycline may cause tooth
discoloration
Table 1: Advantages of Metronidazole.
Advantages of Metronidazole
Ready availability
Rapid bactericidal action
Good tissue penetration
Cost effectiveness
Acceptable pharmacokinetics and pharmacodynamics
Undiminished antimicrobial activity
Inability of susceptible organisms to develop resistance
2.5 OTHER APPLICATIONS:
Metronidazole has also been used along with dental
materials to provide antibacterial properties which can
prevent the harmful effects caused by bacteria. Antibacterial
glass ionomer cement(GIC) when used as a liner had
delivered preservation of dental tissue and reduced risk of
pulp exposure, need of repairing the remaining dentin is
consistent with in the limits of minimal invasive dentistry.17
Ferreira and co-workers,18 had evaluated the performance of
GIC added with antibiotics (1% metronidazole,
ciprofloxacin and cefaclor) for sealing infected dentin in
atraumatic restorations of primary molars. They found
showed higher success rate for glass inomer with antibiotics
rather than conventional, which shows its reasonable use as a
liner when used in primary molars.
3. CONCLUSION
Thus metronidazole has several uses in paediatric dentistry
for decades, such as an obturating material, an intra-canal
medicament, oral administration during pulp therapy as well
as in triple antibiotic paste for endodontic regenerative
procedure and many other varied uses. Further studies were
recommended on metronidazole and its uses in paediatric
dentistry.
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Conflict of Interest: None
Source of Funding: Nil
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IIIIIIIII© International Journal of Pharma Research and Health Sciences. All rights reserved